Reducing acute care hospitalizations from nursing homes is a patient safety priority. This cluster-randomized controlled trial compared a multimodal quality improvement intervention at long-term care facilities and found no difference in the rate of acute care hospitalizations compared to usual nursing home care. These results emphasize the challenge of improving safety outcomes in real-world clinical settings.

Surgical team communication is an important element of safe care. This project report describes how one hospital implemented a checklist program that utilized time outs and debriefings to support transparency and improve surgical teamwork behaviors.

Nurses' working conditions have been shown to affect patient safety. This study found that nurses working successive 12-hour shifts accrue significant sleep debt, regardless of whether these shifts occur in the daytime or at night. Further work should examine the effects of nurse fatigue on patient outcomes.

Prior studies have shown that older patients are particularly vulnerable to medication errors. This cohort study documents a marked increase in both hospitalizations due to adverse drug events and in Medicare patients between 2000 and 2008. During that time frame, the incidence of in-hospital adverse drug events and the severity of harm experienced by patients rose as well.

While computerized provider order entry (CPOE) is widely recommended, studies of CPOE have produced varying estimates of its effect on medication errors, and recent research has raised the concern that unintended consequences of CPOE may outweigh its benefits. This systematic review sought to determine the overall effect of CPOE on medication safety across different hospitals and patient populations. Overall, CPOE did reduce medication errors in both adults and children, but patient outcomes were not affected. The authors note that variability in error measurement and the types of CPOE systems used makes it difficult to generalize the results of specific studies. A prior review also found that health information technology in general, including CPOE, was not associated with significant improvements in patient outcomes.

The authors discuss the value of near-miss reporting within the long-term care environment and recommend strategies for implementing reporting systems.